EMBLEMHEALTH HIPAA Transaction Standard Companion Guide Refers to the X12N Implementation Guide 005010X222A1: 837P Health Care Claim Professional Transaction
HIPAA Readiness Disclosure Statement The Health Insurance Portability and Accountability Act (HIPAA) was signed into federal law on August 21, 1996. HIPAA mandates standards for electronic data interchange (EDI) transactions and code sets, and establishes uniform health care identifiers for providers, health plans and employers. EmblemHealth has been following the evolution of the Administrative Simplification provisions of HIPAA since its inception in 1996. Our goal is to ensure our systems, supporting business processes, policies and procedures successfully meet the standards and implementation deadlines mandated by the United States Department of Health and Human Services (DHHS). To achieve this goal, we have accomplished or are in the process of accomplishing the following: Formed an Executive HIPAA Steering Committee Established a HIPAA Program Management Office Completed an impact assessment on business processes and systems Developing and implementing HIPAA education and awareness programs Identifying specific remediation projects necessary to mitigate or diminish actual or potential exposures Assessing the impact the HIPAA requirements may have on our products, programs and services Evaluating our business processes and best practices to realize the benefits of Administrative Simplification Compliance with HIPAA requires the use of ANSI ASC X12N (version 5010) transaction standards and implementation guides. The rules for transactions and code sets (version 5010) are scheduled to go into effect January 1, 2012. EmblemHealth will be compliant by January 1, 2012. The rules and regulations adopted under HIPAA apply to covered entities (health plans, health care clearinghouses and health care providers) that transmit health care data electronically in transactions covered under HIPAA. All covered entities must comply with the standards adopted by HIPAA by the January 1, 2012, compliance date. 2 of 10
Preface This Companion Guide to the ASC X12N Implementation Guides and associated errata adopted under HIPAA specifies the data content for electronically exchanging information with EmblemHealth. Transmissions based on this Companion Guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to provide information within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or use of data expressed in the implementation guides. 3 of 10
Testing 5010 Transactions with EmblemHealth To assist our providers and trading partners with the transition from version 4010 A1 to version 5010 errata, we will provide a Web-based testing environment where our providers and trading partners can self-test transactions against EmblemHealth s standards. The objective is to enable each of our providers and trading partners to test their files against EmblemHealth guidelines and HIPAA transaction standards edits. We intend to streamline the process by using this Web site to enable you to test online directly against our Companion Guide edits and business requirements. The testing environment is a Web-based application with a self-service portal allowing our providers and trading partners to sign in and participate in tasks designed to assist in the validation of 5010 errata test files. EmblemHealth-Specific Information for Electronic Transaction The table on the following page identifies EmblemHealth-specific requirements for 837P 5010A1 implementation using available data contained in the implementation guide. The table defines specific segments/loops by: Field size limitation Data element code limitation Entry of specific field data Mandatory use of a situational segment Please note that: EmblemHealth requires the submission of the member identification number as displayed on the member s ID card. No Social Security numbers will be accepted. EmblemHealth can only accept a single ISA/IEA (Interchange Control Header/Interchange Control Trailer). For each ISA/IEA interchange, EmblemHealth can only accept one (1) GS/GE (Functional Group Header/Functional Group Trailer). Within the GS/GE Group, a submitter can submit either a single or multiple ST/SE (Transaction Set Header/Transaction Set Trailer). For files submitted with either a single ST/SE set or multiple ST/SE sets, EmblemHealth recommends limiting the total number of claims within each ST/SE set to a maximum of 5,000. EmblemHealth will not support a single transmission containing different transactions, such as an 837 (claim) and a 276 (claims status request). A trading partner may submit more than one (1) transmission per day. EmblemHealth will not support the electronic submission of adjustments to previously processed claims. 4 of 10
COORDINATION OF BENEFITS Effective May 22, 2015, EmblemHealth now accepts electronically submitted commercial coordination of benefit (COB) claims. COB is a way of coordinating benefits when a member is covered by more than one health care plan to ensure that members receive the benefits to which they are entitled and that claims are paid correctly by the health plans. 5 of 10
EmblemHealth Data Elements For Processing v5010a1 837P Transactions Loop ID Reference Name Codes Length Comments ISA Interchange Control Header ISA01 Authorization Information 00 ISA03 Security Information 00 ISA05 Interchange ID ZZ ISA06 Interchange Sender ID NOTE: New Sender IDs will be established for the 5010 format. Please confirm your Sender ID with EmblemHealth. Direct Submitters use the EmblemHealth-assigned three (3)-digit Biller Number. Right pad with spaces to fifteen (15) characters. ISA06 Interchange Sender ID ISA07 Interchange ID ZZ ISA08 Interchange Receiver ID Clearinghouses use your Submitter ID. Right pad with spaces to fifteen (15) characters. Use these values for submission to the respective plan: GHI HMO 255311997 GHI PPO 135511997 HIP 552470001 VYTRA 222647447 GHI MEDICARE PFFS 229370001 Right pad with spaces to fifteen (15) characters. ISA13 ISA14 ISA15 GS GS02 GS02 Interchange Control Number Acknowledgement Requested Usage Indicator Functional Group Header Application Sender s Code Application Sender s Code to the Interchange Control Number in IEA02. Right justify and left pad with zeros to nine (9) characters. Each submitter must start with a value of 1 and increase by one (1) each EmblemHealth will use the TA1 transaction in the event of a file failure. Providers and trading partners must populate with T for test files and P for production files. Direct Submitters use the same value entered in ISA06. Clearinghouses use the same value entered in ISA06. 6 of 10
Loop ID Reference Name Codes Length Comments GS03 Application Receiver s Code Use these values for submission to the respective plan: GHI HMO 255311997 GHI PPO 135511997 HIP 552470001 VYTRA 222647447 GHI MEDICARE PFFS 229370001 GS06 Group Control Number to the Group Control Number in GE02. Each submitter must start with a value of 1 and increase by one (1) each GS08 Version Identifier Code Version Identifier Code must refer to the X222A1 version or file will be rejected. ST Transaction Set Header to the Transaction Set Control Number in SE02. Left pad with zeros ST02 Transaction Set Control minimum of four (4), maximum of nine Number (9) characters. Each submitter must start with a value of 0001 and increase by one (1) each ST03 Implementation Convention Reference Use the same value entered in GS08. BHT BHT02 BHT03 BHT06 Beginning of Hierarchical Transaction Transaction Set Purpose 00 Code Transaction Type Code 1000A NM1 Submitter Name 1000A NM109 Identification Code 1000A NM109 Identification Code 1000B NM1 Receiver Name 1000B NM103 Name Last or Organization Name CH or RP Enter a unique value for every file submitted. If submitting multiple ST/SE segments within a single file, or submitting multiple files on the same day, the value in BHT03 must be unique. The appropriate value for direct submitters to HIP is RP. All other submitters use CH. Direct Submitters use the same value entered in GS02. Clearinghouses use the same value entered in GS02. If NM109 is: GHI HMO is 255311997 GHI PPO is 135511997 HIP is 552470001 VYTRA is 222647447 GHI MEDICARE PFFS is 229370001 7 of 10
Loop ID Reference Name Codes Length Comments 1000B NM109 Identification Code Use these values for submission to the respective plan: GHI HMO 255311997 GHI PPO 135511997 HIP 552470001 VYTRA 222647447 GHI MEDICARE PFFS 229370001 2000A PRV Billing Provider/Pay-To Provider Specialty Information 2000A PRV01 Provider Code BI 2010AA NM1 Billing Provider Name 2010AA NM108 Identification Code XX 2010AA NM109 Identification Code 10 National Provider Identifier (NPI) 2010AA REF Billing Provider Secondary Identification Required 2010AA REF01 EI or SY 2010AA REF02 9 Enter either your nine (9)-digit Tax ID or nine (9)-digit Social Security 2010AB NM1 Pay-To Address: Name 2010AB N3 Pay-To Address: Address 2010AB N4 Pay-To Address: City, State, Zip Code 2010BA NM108 Identification Code MI 2010BA NM109 Identification Code 2010BB NM1 Payer Name 2010BB NM103 Name Last or Organization Name 2010BB NM108 Identification Code PI 2010BB NM109 Identification Code 2300 CLM Claim Information 2300 CLM05-3 Claim Frequency Type Code 2300 DTP Date Referral Date 2300 DTP03 Date Time Period number. Required when the payment address is different from the Billing Provider address. Claims should be submitted with the member ID as shown on the ID card. Depending on the member s plan, the member ID will be 8, 9 or 11 digits. GHI HMO GHI PPO HIP VYTRA GHI MEDICARE PFFS 229370001 Use these values for submission to the respective plan: GHI HMO 255311997 GHI PPO 135511997 HIP 552470001 VYTRA 222647447 GHI MEDICARE PFFS 229370001 All claims will be processed as Original Claims. This date is required when using Loop 2300, Segment REF Prior Authorization or Referral Number. 8 of 10
Loop ID Reference Name Codes Length Comments GHI HMO and HIP plans use this 2300 REF Referral Number or Prior Authorization segment. Value should be supplied if available and applicable to the submitter. 2300 REF01 Using 9F for Referral Number or G1 for Prior Authorization is acceptable. 2300 REF Claim Identification Number for Clearinghouses or Other Transmission Intermediaries Clearinghouses enter your fifteen (15)-digit claim identifier. This 2300 REF02 Clearinghouse-generated control number is used to uniquely identify a claim. 2300 HI Health Care Diagnosis Code EmblemHealth cannot process claims without a diagnosis code, therefore this segment becomes required for all claim submissions. 2310B NM1 Rendering Provider Name Required when the Rendering Provider information is different from the Billing Provider information. 2310B NM108 Identification Code XX 2310B NM109 Identification Code 10 National Provider Identifier (NPI) 2310C NM1 Service Facility Location Name Use when the address of the service is different from the address of the Billing Provider. 2310C N3 Service Facility Location Address 2310C N4 Service Facility Location City, State, Zip Code 2400 SV1 Professional Service 2400 SV101-1 Product/ Service ID HC EmblemHealth will only accept HC. 2400 SV103 MJ Use MJ when billing for anesthesia Units or Basis for or services by use of the anesthesia or Measurement Code UN surgical procedure codes. 2400 SV104 Quantity Value must be greater than zero (0). 2400 REF Referral Number GHI HMO and HIP plans use this segment. Value should be supplied if available and applicable to the submitter. 2400 REF01 2400 REF Prior Authorization 2400 REF01 2400 REF Prior Authorization or Referral Number 2400 REF01 9F G1 GHI HMO and HIP plans use this segment. Value should be supplied if available and applicable to the submitter. GHI HMO and HIP plans use this segment. 9F for Referral Number or G1 for Prior Authorization is acceptable. 9 of 10
Loop ID Reference Name Codes Length Comments SE Transaction Set Trailer SE02 GE GE02 IEA IEA02 Transaction Set Control Number Functional Group Trailer Group Control Number Interchange Control Trailer Interchange Control Number to the Transaction Set Control Number in ST02. Left pad with zeros minimum of four (4) characters to a maximum of nine (9) characters. Each submitter must start with a value of 0001 and increase by one (1) each to the Group Control Number in GS06. Each submitter must start with a value of 1 and increase by one (1) each to the Interchange Control Number in ISA13. Right justify and left pad with zeros to nine (9) characters. Each submitter must start with a value of 1 and increase by one (1) each EmblemHealth Contact Information Please direct questions or any correspondence to: EmblemHealth EDI Operations Call Center at 212-615-4362. 10 of 10